Provider Demographics
NPI:1033493796
Name:EDWARDS, BRENDA R (BHRS)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:R
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30611 W COUNTY ROAD 1230
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-1762
Mailing Address - Country:US
Mailing Address - Phone:918-441-5764
Mailing Address - Fax:
Practice Address - Street 1:30611 W COUNTY ROAD 1230
Practice Address - Street 2:
Practice Address - City:STIGLER
Practice Address - State:OK
Practice Address - Zip Code:74462-1762
Practice Address - Country:US
Practice Address - Phone:918-441-5764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid